MEDICARE: DR. SIDNEY HERSZENSON M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician	18537	WI

General Provider Information

NPI Number	:	1841264074
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SIDNEY HERSZENSON M.D.

Provider Business Mailing Address
First Line	:	801 YORK ST
Second Line	:
City	:	MANITOWOC
State	:	WI
Zip	:	54220-4630
Country	:	US
Telephone Number	:	866-630-9882
Fax Number	:	920-683-2131

Provider Business Practice Location Address
First Line	:	2600 N MAYFAIR RD
Second Line	:	SUITE 810
City	:	MILWAUKEE
State	:	WI
Zip	:	53226-1309
Country	:	US
Telephone Number	:	414-771-1122
Fax Number	:	414-771-1352

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/14/2006
Last Update Date	:	02/17/2014

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